Endocrine Abstracts

Menopause may cause a constellation of symptoms associated with reduced quality of life. Loss of libido is a common one, although there still is uncertainty about its management in clinical practice. This 50-year-old lady was seen in the endocrine clinic complaining about fatigue and loss of libido. The patient’s journey started 3 years earlier when she was commenced on hormone replacement therapy (HRT) in the community. After a short treatment with Evorel Sequi, as libido was not improving, the patient was referred to the endocrine clinic. HRT was stopped to perform a full hormonal screening that came back unremarkable. The patient was started on a new HRT regimen, according to her preferences, with Oestrogel 3 pumps/day and Utrogestan 200 mg/12 days. Additionally, the patient was also advised to start Testogel 2%, half squirt a day for 2 weeks, with an indication to increase the dose to one squirt a day if needed. A few months after starting this regimen, the patient’s libido significantly improved, however, she started experiencing some hair growth. On a routine blood test, oestradiol and testosterone levels were significantly elevated (>x3ULN). The patient was reviewed by her GP who stopped Testogel and reduced Oestrgoel to 1 pump/day. When the patient was seen at our clinic, she was complaining about significant fatigue and loss of libido since changing the HRT. Moreover, since starting oral Utrogestan, experienced some headaches and nausea, although preferring to continue oestrogel rather than restarting the patches. She was reluctant to change the HRT again and resigned to her new quality of life. During the consultation the patient reported to have been taking Fluoxetine 20 mg/day for a long time, to help her depression/anxiety secondary to family issues. After a long consultation, the patient accepted the advice to increase Oestrogel to 2 pump/day, try to switch Utrogestan to Norethisterone Acetate 5 mg/12 days, switch Fluoxetine 20 mg to Mirtazapine 15 mg/day, and speak with GP if feeling in need of mental health support. Six months later, the patient reported a significant improvement in her fatigue and libido, not requiring to restart testosterone anymore. Libido management might be difficult during menopause, however selecting the right HRT as well as treating the interfering causes, can lead to improvement of symptoms without testosterone treatment.